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BIRTHING AN EPISTEMOLOGICAL
SHIFT: THE DISCURSIVE FUNCTION
OF EIGHTEENTH-CENTURY
OBSTETRICS MANUALS
RHI JOHNSON
University of North Carolina, Chapel Hill
“Conviene que sepas lo que haces. Ese seno que vas a
abrir encierra no un ser humano, no una criatura, sino «una
verdad». Fíjate bien. Te lo advierto. ¿Sabes lo que es «una
verdad»? Una fiera suelta que puede acabar con nosotros, y acaso con el
mundo. ¿Te atreves, ¡oh comadrón heroico!, a sacar a luz «una verdad»?”
(Emilia Pardo Bazán: “El Comadrón,” 1901)
Volume 39.1
Spring, 2016
The University of
Virginia
“Luego la criatura se halla en su cabal madurez, incitada de la hambre, y
de la necesidad de respirar, y no cabiendo comodamente en la estrechéz
de la matriz, inclina la cabeza ácia su orificio, y haciendo para hallar su
salida varios movimientos, irrita las membranas del útero, y demás partes
sensitivas, produciendo los grandes dolores, que son causa de que todas
las partes se vayan relaxando, y contribuyendo á la expulsión.”
(Antonio Medina, 1750)
Antonio Medina’s suggestion that birth occurs when a fetus gets
hungry and starts head-butting the uterus may seem strange, a nightmarish
scenario more at home in Ridley Scott’s 1979 Alien than in an obstetrics
textbook, but if truths can be birthed, why then should they not take such a
text for their womb? 1 The didactic texts of the eighteenth century, like
Pardo Bazán’s departed mother, held truths within them, truths that played
on the same fears that her story does: about the womb, female power, and
the unknown. These texts not only contain the hard cold truths of
medicine, but also formed the proving grounds for a host of philosophical
ideas. In the textual creation of the midwife in eighteenth century
obstetrical manuals, in the turmoil of the medical hierarchy, there is
evidence not only of the misogynist power structure that has already been
recognized in the period, but of a clash of epistemologies: between classical
training, the veracity of which was being called into question, and
previously denigrated empirical traditions, the revaluation of which formed
the basis of educational reforms throughout the century. This essay
1 Recent research by URI’s Holly Dunsworth has brought into question the
“obstetric dilemma” that, for decades, has suggested that the ratio of pelvis to skull
size limits gestation. She credits instead the mother’s metabolic ceiling, or highest
sustainable basal metabolic rate (Wayman). While fetal agency is absent, birth does
happen, in a way, because the fetus gets hungry!
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Johnson, "Eighteenth-Century Obstetrics Manuals"
examines the philosophical discourse that exists alongside the scientific
content of physician Antonio Medina’s Cartilla nueva util y necesaria para
instruirse las matronas que vulgarmente se llaman Comadres en el oficio de Partear
(1750), and fellow medical practitioner Juan de Navas's Elementos del arte de
Partear (1798),2 as well as in Benito Jerónimo Feijoo’s published letter “Uso
más honesto de la arte Obstetricia” (1747).
These texts have been treated to an extreme paucity of literary analyses
to date. This lack, perhaps owing to their supposed utilitarian function, is ill
conceived, since that focus on usefulness is, in itself, a key element of the
philosophy of Spain’s enlightenment reformers. This led to the inclusion of
much sociological and philosophical discourse within texts that hold utility
as their main function.3 It is this peripheral content that this essay examines,
focusing on authorial asides, explanatory material, and choices of diction, as
well as threads that tie the three texts together. The earliest of the three
texts that I examine, Feijoo’s letter, which was included in the second tome
of his Cartas curiosas y eruditas (1747), offers entry to the state of social
discourse on the male versus female midwife, in its bureaucratic, systemic,
and social contexts, at the outset of attempted reforms. 4 This letter’s
consequence, and the weight of Feijoo’s voice, can be seen in the
publication of Medina’s book three years later, at the behest of the
Protomedicato, to serve as the instructional manual for the licensure
examinations of midwives, which were established in the same year
(Usandizaga 238).5 Though this book is brief and intentionally focused on
the most basic elements and techniques of the trade, its philosophical
discourse suggests a beginning to an epistemological shift in the medical
establishment, in the face of great social need, and the eighteenth-century’s
rapid modernization of surgical and medical practices. Navas’s Elementos del
arte de Partear, published at the end of the century, is the more scientifically
accurate of two contemporaneous texts that present the state of obstetrical
2
Citations in this text come from an 1815 reprint.
The Spanish Enlightenment was not a movement of the populace, but rather one
of the liberal-minded subset of the elite, struggling against a more conservative
populous. These ilustrados, inheritors of the reformist attitude of the preenlightenment novatores and supported by the new Bourbon dynasty, pushed for
public utilitarian education, empirical modes of study in the sciences, and the
questioning of knowledge and beliefs supported only by tradition or Church
dogma. For a background on the movement, see Deacon.
3
4 While this letter is frequently mentioned in medical histories, it has not been the
object of extended study to date. For background on the author, see McClelland.
5 The Protomedicato is the regulatory body that had sole jurisdiction throughout
the period in respect to the regulation of physicians, surgeons, apothecaries, and all
such persons as were engaged in healing (Granjel 92).
DIECIOCHO 39.1 (Spring 2016)
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knowledge at the time (Granjel 224). While the text is composed of two
large tomes, detailing anatomy and procedures, I focus on the author’s
history of obstetrics and commentary on the state of the field, which form
the introduction to the text. It is there that Navas’s contribution to the birth
of a socio-scientific truth is most clearly visible. To give an example of the
breadth of his work, see the first of four pages of the table of contents of
the first volume (Figure 1).
Figure 1. Don José de Navas, Elementos del Arte de Partear
(Madrid: Imprenta de Sancha, 1815)
When Feijoo published his letter, as Michael Burke discusses in his
history of the Royal College of Surgery at San Carlos (1975), Spain’s
university programs for medical education were so steeped in solipsism, so
firmly entrenched in the study of Hippocratic disease theories and
Aristotelian metaphysics, and so distanced from actual patients or cadavers,
that one could be licensed a physician without ever having dissected a body
(23). While the early seventeenth century had seen Spain’s physicians
among the best in Europe, that grandeur, if not the pride associated with it,
had long since fallen away. In 1625, the medical faculty at the University of
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Salamanca restored Galen in place of Vesalius, and enacted no further
academic changes until 1770 (45). Yet these university-trained physicians,
the only medical branch based in extended, institutional study, held the
highest socioeconomic position of any healer, and looked down on other
providers: surgeons, barber/bloodletters, and midwives, all of whom were
trained empirically by apprenticeship and who honed their skills through
practice rather than theory (Usandizaga 227). Yet, even at the height of this
stratification of power, the medical elite, the power behind the university
system, realized that a lay surgeon knew more anatomy than a universityeducated physician (Burke 47).
This dichotomy between prestigious training and practical skill, along
with medicine’s contact with both classical theory and the natural sciences,
is in part responsible for the fact that medical texts are a useful vehicle for
the discussion of the societal exigencies that confronted efforts at reform.
Indeed, the practice of medicine was seen as representative of the general
shortcomings of Spanish science by Feijoo and the ilustrados (Burke 16-17).
Crucial for this essay is that through their engagement with the overarching
state of medical education, these texts position the female provider in terms
of the male hegemony and the problems of access that cement the her as a
crucial player in the medical field. What is more, public health reform not
only had the potential to be visible, but also to be immediately beneficial to
a population that was generally conservative and uncomfortable with the
very idea of systemic change (17).
Spain’s populace, the seemingly immovable object against which the
ilustrados thrust their ideas, is key in entering into any text of Feijoo’s that
is aimed at a public audience (whether explicitly, or behind a direct address
to an anonymous patron).6 Feijoo stated, with all plainness, the disdain that
he held for his public. In “La voz del pueblo,” he asserted that “el valor de
las opiniones se ha de computar por el peso, no el número” (1). Nor were
intellectual circles free from his critique of common thought, as he held that
educated persons were just as likely to deny the usefulness of new
knowledge, in an attempt to maintain their status (Burke 6). Even in the
first paragraph of “Uso mas honesto de la arte Obstetricia,” Feijoo
reiterates his disgust for his readership through a rhetorical question asked
of his imagined sole reader: “Pero, señor mío, ¿qué puedo yo en esta
materia decir al Público, que el mismo Público ignore?” (235). Because of
this desire and repeated intention to dispel long-held but problematic social
and academic notions, it becomes useful to discuss not only Feijoo’s
message, but also his rhetorical strategies.
Critical treatment of “Uso mas honesto de la arte Obstetricia” has
assumed that it is supportive of male midwives and surgically trained birth
attendants who were entering the traditionally female sphere of the birthing
6 For
a study of this eighteenth century public, see Medina Domínguez.
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87
chamber in unforeseen numbers, and that the letter and its writer opposed
the practice of the female midwife.7 In his Historia de la Obstetricia y de la
Ginecología en España, M. Usandizaga references Feijoo’s letter as one of
support for the dominance of male practitioners: “defendiendo la
intervención de los hombres por más competentes y más capaces” (215).
Nevertheless, I claim that this assumption of a misogynist narrative in
Feijoo’s letter only makes sense in a reading of its surface level criticism. As
the most blatant example of such criticism of the female practitioner, Feijoo
says “[l]as mugeres son ignorantíssimas del Arte, que para él se requiere. Mil
lamentables casos están descubriendo cada día sus errores” (235). The
shortsightedness of a valorization of the letter that looks no further than
this open critique of female providers is key to understanding both his
message and the social state at the time of his writing.8 While it is hedged in
with this kind of anti-midwife rhetoric, the main thrust of the letter is stated
clearly: “Mas si se pudiese tomar providencia para que las mujeres se
instruyesen bien en este Arte, deberían ser excluidos enteramente de su
ejercicio los hombres. ¿Y se podía tomar esta providencia? Sin duda” (237).
In this statement not only is Feijoo’s premise clear: that female care
providers should be educated and have sole providence in the field, but it is
also possible to perceive Feijoo’s means of convincing his public of the
merit of his position. In that attempt at persuasion, it is possible to see the
function of his indemnifications of female competence.
To this end, Feijoo utilizes the social anxieties and prejudices of his
readership. He suggests the impropriety of the male provider’s access to the
female body by emphasizing female modesty as more important than life
itself: “puede una mujer sacrificar la vida a la honestidad, cuando
constituida en una enfermedad, que sólo es curable exponiendo a las
manos, y a los ojos de un hombre lo que más esconde el honor, le es esto, o
igualmente, o más sensible que la muerte” (236). Not only is it appropriate
for a woman to choose death over the touch of a man not her husband, it is
the moral decision: “que más quería morir, que usar del ministerio del
Cirujano; bien que tuvo la dicha de que una mujer le suplió, a quien acaso
Dios con especial providencia dirigió la mano, por premiar aquel acto de
pureza heroica” (236). Feijoo carries this created modesty to an extreme, in
that “cuando llega el caso de ponerlas por algún delito grave en la tortura,
7 Male
purview in the birthing chamber can be marked as entering Spain in 1713,
when the birth of Queen Luisa Gabriela de Saboya’s child was attended by a male
surgeon (Pardo Tomás and Martínez Vidal 49).
Pardo Tomás and Martínez Vidal, in “The Ignorance of Midwives: The Role of
Clergymen in Spanish Enlightenment Debates on Birth Care,” explore the
temporary nature of Feijoo’s support of male attendants, but do not discuss the
persuasive function of his use of anti-midwife rhetoric.
8
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Johnson, "Eighteenth-Century Obstetrics Manuals"
sienten más la desnudez, que los cordeles” (237). This clearly hyperbolic
construction illustrates the intentionally ironic seriousness with which he
treats the topic.
The only element described in this letter that makes the death of a
woman in labor problematic, thereby validating the existence of the field of
obstetrics, falls fortuitously in line with one of the most intense social fears
of Feijoo’s deeply religious audience: limbo. This is visible in how he
differentiates death by disease from death by childbed: “en el primero sólo
insta la conservación de la propia vida, y en el segundo también el
salvamento, así eterno, como temporal del feto” (237). Through these two
messages, Feijoo sets up a rational argument against the male midwife:
women are right to prefer death to the touch of a male surgeon, but it is
immoral to choose death when the life and soul of a fetus are at risk.
He continues, sweetening the rational answer for his readers by
appealing to the stereotypes and prejudices that he assumes them to hold.9
This is evidenced by the letter’s final sentiment, which reiterates his
solution, while corroborating a negative social perception:
La debilidad, o poca fuerza de las mujeres es patente a todo el mundo.
[…] Pero no hay experiencia alguna de que las mujeres sean ineptas para
el uso de la Cirugía. Y en fin, sea lo que fuere de la Cirugía tomada en
toda su extensión; para la particular obra de facilitar el puerperio, supuesta
igual enseñanza, no veo por dónde se pueda asignar a los hombres alguna
mayor disposición que a las mujeres. (240)
Allowing women access to medical training and making them licensed
providers, especially if their purview is restricted to the ills of women, does
not have to destroy the opinion of women held by his readership -that
women are both weak and stupid.10 This assumption of prejudice should
not, however, be read as representative of Feijoo’s own opinion. While his
argument allows his readers to hold to their beliefs, these popuarly accepted
products of the collective consciousness, like inherent female weakness, are
the type of sentiment that Feijoo and other reformers, in the tradition of
9 An analysis of Feijoo’s discussion of the mother’s and midwife’s role in both life
and birth could counter the contention that “Uso más honesto de la arte
Obstetricia” deviates strongly from his argument in “Defensa de las mujeres,” but
lies outside the scope of this essay.
10 This use of social and religious angst to create a persuasive argument in a
scientific discourse finds a deeper theoretical basis in Paul Ilie’s discussion of
epistemological belief in the context of the enlightenment as a system of
connections dependent on cohesion of ideas, whether rationally or dogmatically
based. This idea allows, in this instance, the application of a religious or social
rationalization to form part of a scientific belief system (40).
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the novatores, fought against, and are what led to his low opinion of his
readership.
And yet, the idea of opposition to female practice arises not only in
discussion of Feijoo’s letter, but also in the little critical attention has been
paid to the eighteenth century Spanish midwife. Teresa Ortiz, in “From
Hegemony to Subordination: Midwives in Early Modern Spain” (1993),
constructs the shifting educational and professional systems of the medical
field around the displacement of the female provider, saying: “the
educational reforms reduced their autonomy and relegated them
scientifically and professionally during a lengthy process which lasted
throughout the century” (100). It is easy to see, as she does, the entry of
men into a traditionally female sphere as solely that: an invasion.11 There is,
however, another facet to this surge in male practitioners that merits
mention.
While the evolution of surgery in the eighteenth century sent men into
obstetrics in large numbers for the first time, they did so, in large part,
because of the development of new practices that had the potential to (and
did) save many lives. Surgical advances leading to the performance of
successful Cesarean sections on living women,12 the symphysiotomy,13 and
the development of forceps, all allowed for successful deliveries where
This is the angle that Enrique Fernández followed in his article “Tres testimonios
del control y desplazamiento de las comadronas en españa (Siglos XIII al XVII)”
(2007). where he bases his discussion of gender dynamics off of Ortiz’s, saying “los
estudios existentes […] confirman esta tendencia general al desplazamiento y
control de las comadronas” (91). Yet one of the three works that he discusses
suggests the social merit of the practice of midwifery even by noble women, which
forces him to conclude that “es evidente que la historia de este desplazamiento es
compleja y no se puede reducir simplemente a una narrativa lineal” (99).
11
12 Post-mortem Cesarean sections and the in utero dismemberment and removal of
dead fetuses had existed for centuries, and in the 15th to 17th centuries are
recorded as the purview of midwives, but the development of techniques that made
in vitu Cesareans possible was an 18th century advance, and required different and
more advanced skills than the excision of a fetus from a corpse. These techniques
were a point of great contention during the century, with some practitioners
denying the viability of the operation in vitu until the 1770’s (Usandizaga 242-3).
13 A
symphysiotomy is an operation that, by cutting the cartilage at the pubic
symphysis, can widen the opening of the pelvis by up to 2.5 cm. This can make a
birth possible in the event of a bony obstruction, where the pelvic opening is of a
smaller diameter than the head of the fetus. While a symphysiotomy can lead to a
successful birth, it is an operation from which a full recovery is unlikely, as cartilage
does not easily regrow. It also has very high maternal and fetal morbidity and
mortality rates. This high risk, along with advances in Cesarean sections, has made
the procedure relatively obsolete in today’s world, though it is still performed in
rare cases where a Cesarean is impossible (Cunningham 544, 567).
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previously a fetus would have died and been removed from the womb in
pieces. Advances such as these created an atmosphere where obstructed
labors, ectopic pregnancies, retained placenta, dangerous fetal presentation,
and other complications no longer spelled a certain death sentence for
woman and child (Usandizaga 241-5). These new techniques, however, did
not arise from the tradition of midwifery, which is based on assisting
nature, rather than intervention (Pardo Tomás and Martínez Vidal 49). The
new practices and technologies developed instead in the surgical field, and,
in concert with its growing scholastic presence, expanded it, bringing it into
contact with midwifery. This contact was not simply a matter of the
appropriation by surgeons of the existing practices of the midwife, but
rather the development of new skillsets, that were able to ameliorate the
high loss of life that has always been a part of birth.
Given the correlation between the development of new techniques and
the growth of surgery’s influence, the application of a purely misogynist
narrative to the period becomes problematic. Midwives were expected to
defer to surgeons in complicated cases, but there exists a conflation of
educational sexism and professional marginalization in arguments, like
Ortiz’s, that assume that these regulations were designed to make midwives
“withdraw from some of the duties that they had carried out in the previous
century, in order to hand them over to surgeons” (102). It is true, as she
discusses, that women’s education was not equal to men’s, but that
difference does not mean that surgeons’ entry into obstetrics was designed
to excise women.
There is one other crucial element in discussing the narrative of the
disenfranchisement of the female practitioner, particularly in this narrative’s
reliance on an ethos of competition between midwives and medical men
throughout the eighteenth century, an idea borrowed from English and
French experience and often mistakenly assumed to apply to the Spanish as
well (Fernández 91).14 Eighteenth century Spain suffered from a dearth of
medical providers, even including practitioners other than physicians, who
were unregulated through the first half of the century (Burke 24-25).
Granjel’s history of Spanish medicine reveals the extent of this problem. At
the end of the century, after a long period of growth in the numbers of
physicians and surgeons, there was only one surgeon or physician for every
eight hundred inhabitants of a rapidly growing Spain. Furthermore, most of
those professionals were concentrated in urban centers, which left the
majority of Spain’s population with no access to university-trained
practitioners (79). This great need is reflected also in Antonio Orozco
Acuaviva’s work on Italian influence in the period, which suggests that
“ante la falta de profesionales en el último período de la España de los
14 For a description of the correlative experience of the English midwife, see King
(Midwifery chapter 2), Donnison, Achterberg, and Marland. For France, see
Sheridan, Gélis, and Marland.
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Asturias, Felipe V ha de contratar médicos extranjeros para sus ejércitos,
Armada y para la propia Casa Real” (192). This need to import providers to
serve the portions of society otherwise most likely to have access to care is
another strike against the idea of direct and widespread competition
between midwives and male providers. In regard to the profession of
midwifery at this time, Spanish dynamics are different from those of France
and England, and a reassessment of the sort that I develop here is necessary
in order to have a more exact understanding of the period in the peninsula.
Nor did the midwife exist only outside of the university system. The
need for providers throughout the century played strongly into the
regulations and systems of licensure that developed around the practice of
medicine. Even at the end of the century, when most critics assume that the
midwife was on the verge of extinction (Usandizaga 277, Ortiz 95,
Fernández 2), Spain’s continued need was recognized, and is evidenced by
the Protomedicato’s continued amendment of the requirements that it
demanded of midwives as well as surgeons and physicians (Burke 29, 158;
Granjel 93), from the reenactment of licensure in 1750 and throughout the
second half of the century. When Fernando VI passed the law that made
examination of midwives possible, he explained that the poor state of the
art required a re-institution of previously suspended requirements: “El
Tribunal del Protomedicato me ha hecho presente […] muchos malos
sucesos en los partos, provenidos de las mugeres llamadas parteras, y de
algunos hombres […]; dimanando este universal perjuicio de haberse
suspendido el examen que antes se hacía de las referidas parteras por los
Protomédicos” (cited in Burke 216). From that time, guidelines regarding
the demonstration and acquisition of requisite skills only increased in rigor.
Spain’s protracted need for caregivers should be taken into account
when reading texts that suggest problems in the preparation or value of
subsets of the medical population. While, as Ortiz suggests, physicians held
a bad opinion of midwives because “‘the midwives’ craft is a science or a
craft to work with one’s hands” (96), the disinterest verging on disgust that
physicians displayed towards midwives exceeded the bounds of a gender
binary. The struggle was also based on methodologies of education and
professional preparation. Surgeons bore the black mark of the same opinion
from physicians throughout most of the century, while surgery grew from a
horror show of field amputations and bloody screaming death to something
more recognizable as the art that carries the name today. This rift between
branches is rooted in the physicians’ inheritance of their art from the
classical tradition, in contrast with surgeons’ empirical training. “The
physician was a professional, familiar with the classics, and possessing an
academic degree; the surgeon, on the other hand, was an uneducated craftsman
who worked with his hands” [emphasis added] (Burke 25). This divide between
craft and profession discussed in reference to both the midwife and the
surgeon was, in fact, the focus of social upheaval.
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As surgical faculties developed in universities, physicians saw
themselves losing their status as the sole class of university-trained medical
provider, and lay surgeons came into conflict with those who had
undergone university training (30). Even before the inclusion of the
surgeon in the university faculties, the dichotomy between craft and
profession was problematic, because differences in education were not
necessarily qualitative. Surgeons and lay practitioners, like midwives, often
had a great deal more practical experience than classically trained physicians,
which tended to leave these lay practitioner more open to innovation, and
less focused on outdated dogmas (Burke 25). Therefore, the threat that
came from the inclusion of surgery in university medical systems was not
only a threat to the social power and prestige held by the physician, but also
a challenge to the epistemological worldview that created him.
We can, consequently, describe the conflict between physicians and
midwives as indicative not only of a misogynist power structure, but also of
the clash of epistemologies that appears in the institutional aversion to
surgeons (male). The classical example Feijoo uses in “Uso más honesto”
allows a point of entry into the representation of this clash of
epistemologies through a social and linguistic gendering of power. This
example is the tale of Agnodice, an Athenian girl who supposedly practiced
medicine in the fourth century BCE. Although it is unknown if her story is
historically true, it is mythic in discourses on female medical practice from
the Renaissance onwards (King “Agnodice”). Through the retellings of the
same story in both Medina’s and Navas’s texts, it brings us into dialogue
with those works. This recurrence of the myth gives entry not only to the
meshing of literary and scientific discourses that is intrinsic to the era and
the basis of a revalorization of these medical texts, but also hints at the
intersectionality that formed the heart of Enlightenment cultural
expression. The story, which each of our authors fits his own philosophical
ends, is that Agnodice, living in a time when Athens disallowed female
physicians, dressed as a man and learned obstetrics clandestinely.15 After
she began practicing, because she would tell her clients her sex, she became
so popular that the other doctors brought her to trial for misconduct. This
trial made it licit for women to practice midwifery.
Feijoo not only builds his narrative entirely around Agnodice and other
female wielders of agency, but also suggests that in the medical field she is
as capable as any man. He goes so far as to excise almost all ascription of
positive action to male authority figures. Although Agnodice studies under
a physician, the way that he describes her education suggests that she is selftaught: “para cuyo efecto, vistiéndose de hombre, fue a ponerse en la
15 This
historical referent signals the potential mendacity of the source material,
Higinius’s history, as no known point in Athenian history matches with his
description (King “Agnodice”).
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Escuela de un Médico, llamado Hierófilo, de quien no era conocida. En
efecto se instruyó muy bien en la Medicina; y con especialidad en el Arte de
Obstetricar” (237). Feijoo’s use of a reflexive construction of the verbs “to
put” “to instruct” places the agency of education on the student, rather
than the teacher. Agnodice’s practice, once established, is not solely an
obstetrical one, though it is comprised only of women: “se puso a ejercer su
habilidad en Atenas, siempre disfrazada con el hábito de hombre, asistiendo
a las mujeres, no sólo en los partos, mas en cualquiera dolencias, aunque
declarándoles en secreto su sexo, por apartar el estorbo de su pudor”
[emphasis added] (237). Not only do the verbs here continue to build
Agnodice as the creator of her fate, the language places her on par with
male physicians, rather than allowing her only enough proficiency to guide
births. This creation of a masculine persona for Agnodice draws on the
tradition of Spanish Baroque drama, and its trope of the mujer en hábito de
hombre or cross-dressing female character, which was enough of a staple of
seventeenth century comedia that its convention of credibility increases
Agnodice’s transgression: male dress is enough to create the sex, thereby
allowing her access to the privileges of the male population as well as a male
profession.16
The description of the accusations that come against Agnodice cements
the idea of social equality, but also plays on the fears of Feijoo’s
contemporaries to suggest the value of female health care providers,
without having to state such a position outright. By accusing his Agnodice
of sleeping (as a man) with her/his clients, he suggests this as a possible
outcome of having a male practitioner, while shielding himself from
The Spanish mujer en hábito de hombre was often an intentional and morally
justifiable invasion of the sphere of male influence (McKendrick 162), and should
not be confused with the English ‘breeches-role,’ where the focus of the crossdressing is on the scintillating view of female ankles (Howe 56). The convention of
credibility that Feijoo makes use of also comes from the comedia. Even the most
delicate of women, in the dress of a man, would be believed to be male. For
example, in the first act of Calderón’s La vida es sueño, Rosaura’s garb not only fools
the half-wild Segismundo, it also convinces her unknown father that she is his long
lost son: “¡Qué suerte tan inconstante! / Éste es mi hijo, y las señas dicen bien con
las señales / del corazón” (I, 412-15). Rosaura’s true sex is only revealed when it is
only her female honor that her ex-lover could have damaged. Nor did the inherent
believability of such a cross-dressing decrease with time, as is visible in el Duque de
Rivas’s nineteenth century Leonor, the fragile heroine of La fuerza del sino. After
several minutes of speaking with a priest, while in male dress, and after refusing to
enter a cloister: something that for a man suggests excommunication, but that for a
woman is the most moral choice, she reveals herself to him: “Doña Leonor: (Muy
abatida): Soy una infeliz mujer” (II, 522). To this shocking revelation, the priest
responds: “Padre Guardián (Asustado): ¡Una mujer!... ¡Santo cielo! / ¡Una mujer!... A
estas horas / en este sitio…¿Qué es esto?” (II, 523-5). Men’s clothing in itself
makes for the male character, and an assumption of the prerogatives of masculinity.
16
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rebuttal against that sentiment by putting it not only in someone else’s
words, but in a male, powerful, and plural someone else. It was the physicians
of the city who “se conjuraron contra ella; y como estaban en la persuasión
que era hombre, la acusaron en el Areópago de ilícitas intimidades con el
otro sexo; añadiendo, que muchas mujeres se quejaban de dolencias, que no
padecían buscando este pretexto para lograr su torpe comercio, con el
lampiño Mediquito” (237). This suggestion that a male (but not really)
physician might have illicit contact with his patients is exactly the kind of
unnatural and unacceptable contact that formed Church and social
opposition to the practice of male midwives, until fear of professional
females overwhelmed that previous discomfort. That this accusation comes
from a group of socially powerful males, who, as representatives of the
Athenian power structure, are opposed to female midwives, puts that
corollary on Feijoo’s readership. This identification in turn leads his readers
down the path toward acceptance of the safety of female birth attendants.
The trial itself forms a final point of support for the female voice in
matters of women’s health, in that the agency behind the decision that
opens the practice of medicine in Athens is female: “Pero sabedoras del
caso las Damas Atenienses, intervinieron en la causa, e hicieron tanto, que
lograron se abrogase aquella ley; con que quedó triunfante Agnodice, y se
declaró a las mujeres el derecho de ejercer el Arte, que ella ejercía” (238).
Not only are the women of the city suggested as the group that swayed the
verdict, and not only does Agnodice stand triumphant, there is no direct
mention of the governing body that overturned the law. The passive
construction that allows for the victory leaves the women as the only active
participants, apart from the physicians, who, though they represent the
readers of the “Uso más honesto,” lose.
When Medina takes up this same myth three years later in his Cartilla
nueva y útil, and Navas, in Elementos del arte de Partear, the constructions of
gendered power dynamics offered (exhibited through means of education,
field of practice, and the power breakdown in the court) shift radically from
Feijoo’s representation. Medina’s recounting of the tale, while brief, is no
less important in its demonstration of his overarching message. As he tells
it, “Agnodice fue acusada porque exercía el oficio de Partear en trage de
hombre, y que declarado su sexo resolvió el Senado de Atenas, que este útil
oficio solo fuese permitido á las Mugeres” (iv). While some of the
differences, such as the lack of discussion of Agnodice’s education, can be
attributed to the brevity of the telling, the power structure in his version is
substantially different.17 The privileges that Agnodice wins, while following
a similar didactic course to Feijoo’s, in that they suggest that women can
equal men in obstetrical practice, construct a different solution for the
gendering of power in the art. The office that Agnodice wins is more
17 Though his Agnodice is not named an auto-didact, the very title of his book uses
the same reflexive construction as Feijoo’s recounting of the myth.
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limited: midwifery alone rather than all medicine, but after the legal
proceedings only women may practice the art, which gives her greater
autonomy than was granted by the earlier version.
While the accusing body in Medina’s rendition is not named, the power
in the senate’s decision does come straight from a governing body. There is
no doubt that the right to regulate healthcare providers comes from the
government. The only active, temporally determined verb in his telling is
“resolvió” (it resolved): that is the true action of the story -the senate’s
decision. In this just, powerful, male governing body, there is a corollary to
Medina’s support of the Protomedicato. This intrinsic support of regulation
and the Protomedicato’s aims is all the more clear in that his recounting of
the story of Agnodice is followed by another classical anecdote suggesting
that the Roman senate also licensed and regulated providers: “habían de
poseer reglas y estudio, mediante el qual mereciesen la aprobación” (v). It is
by study and licensure (by the regulatory mechanism of a bureaucracy) that
the female practitioner should be licit. Medina breaks here from Feijoo’s
encouragement of passion and aptitude, suggested in his iteration of the
myth by self-study and lack of regulation, and focuses instead on the
importance of a governmental regulatory body for a functional medical
system.
By the time that Navas published Elementos del arte de Partear, and
therefore his version of the story of Agnodice, the societal framework
around obstetrics and midwifery had developed substantially. In 1794, when
the obstetrical course that was part of the surgical curriculum at San Carlos
was increased in length to a full year, the university enacted free classes to
train midwives in anatomy and best practices, because the numbers of
surgeons coming out of the program “would have little effect on the
tremendous loss of life associated with childbirth” (Burke 98). It is
apparent, in the creation of this class at the end of the eighteenth century,
that male practitioners had not thrust women out of the birthing room, and
that they were still integral to societal wellbeing. What is more, this
cognizance was not only held by the governing heads of the educational
bureaucracy that composed both the college and the Protomedicato, but
extended to governmental ministries and influenced policy. The first eight
midwives to go through this training were hired by the municipal
government to oversee sections of the city, and to train other midwives
within that purview to increase the standards of care (98). These courses,
while not the same training as was received by surgeons, were better than
any available previously, and were aimed at retaining providers, and raising
the availability of care in an underserved population. Furthermore, while
surgical colleges were never able to complete enlightened reforms due to
governmental financial restraint, not only were these classes for midwives
free, midwives’ licensure was substantially less expensive than that of
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surgeons (Burke 158, 192).18 The creation of these classes, in conjunction
with the obstetrical surgical training that the school provided, was designed
to “improve the practice of obstetrics without driving women out of medicine”
[emphasis added] (Burke 100). Professional training only raised the social
prestige of the midwife, much as it did for the surgeon (Usandizaga 217).
Navas’s iteration of the tale of Agnodice, because of his retrospective
position in regards to these reforms, balances the other two that we have
seen. He villainizes the male populace for forcing women to rely on male
doctors, saying that women would call Agnodice in order to: “vengarse de
los que pretendían violentar el pudor del bello sexo, y obligarlo por falta de
comadres á parir delante de los médicos” (xi). This, without equivocation,
promotes the female provider, and through her the more empirically based
system of learning that produces her. At the same time, however, he
removes Feijoo’s suggestion that Agnodice penetrated the world of men,
and sidesteps any suggestion of sex in the court proceedings: “acusaron á
Agnodice de que siendo eunuco, según su esterior, corrompía las buenas
costumbres de las señoras” (xi).19 While he does allow a female voice some
influence in changing the mind of the senate -“El bello sexo mas
distinguido de Atenas […] se presentó al Senado manifestándole la temeraria resolución de que primero se dejara morir, que llamar á los hombres
para que le asistieran en los partos” (xi)- the power of decision stays with
the governing masculine body: “Semejante despecho consternó al Senado,
y éste revocó la sentencia dada contra Agnodice, y espidió segundo decreto
permitiendo á las mugeres el ejercicio de la Medicina en las enfermedades
de su sexo” (xi). This outcome too is softer than either of the others,
neither restricting women’s practice to solely obstetrics, nor suggesting that
men should be disallowed the office.
The diachronic perspective offered by Feijoo’s, Medina’s and Navas’s
three presentations of the same myth offer an entry into the political
discourse of the authors and their times. Medina’s construction of the myth
forms a declaration of support for the Protomedicato and its request for the
Cartilla nueva y útil, through its focus on the male agency of the outcome,
and the limitations placed on the sphere of influence of the female
practitioner. These elements support the idea of a regulatory body’s
At the beginning of the nineteenth century, the examination fee for surgeons was
2,500 reales, that for bleeders 2,000, and that for midwives 800 (Burke 158-9). For
comparison, a loaf of bread cost about 1.25 reales, and a pound of mutton about
2.25 (Hernández Franco 95-96).
18
19 The
sexually incapable male, alluded to in the description of Agnodice as a
eunuch, was a subject of much debate in the period, due to both the castrato opera
singer Farinelli and growing unease regarding the creation of castrati, though the
operation was deemed safe, even curative, by the same Hippocratic teachings that
were under fire in the birthing chamber (Rosselli 145).
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decision to register midwives as a strong move, offering a classical
foundation for such an idea to non-midwife readers of the text, in order to
increase the possibility of popular approbation for the program of
education and regulation that initiated his writing. Feijoo, in contrast, wrote
before such a plan had been set in action, which led to his use of social
anxieties to incite action. From his retrospective position, at a point in
history where medical faculties had reconnected with the importance of
empirical observation, and the midwife and surgeon both had opportunities
for training, Navas draws the middle line between the two: still building a
firm approbation of a medical bureaucracy, but without completely excising
female agency. Through this comparative reading, the political landscape of
the field of obstetrics can be seen to unfold, based around the authors’
support for empirical education.
The gendered dynamics of power that appear in the myth of Agnodice
are something that continue throughout these works. The supposition of a
female voice of authority or position of superiority relates directly to the
clash of epistemologies, as it takes power out of the hands of the doctrinally
trained, and lays it at the feet of an empirical tradition. In Feijoo’s second
example of women’s capacity to practice, the unnamed daughter of German
surgeon Mr. Sabary is witnessed by a Parisian surgeon in successful
performance of a Cesarean section, an operation that Feijoo calls “la más
ardua que hay en toda la extensión de la Cirugía” (239). While the
foreignness of this successful, contemporary female practitioner protects
Feijoo from too direct of criticism, his reference to Paris is clearly positive,
given his Bourbon patronage.
In concrete support of the female provider, Medina repeats time and
again that she should have predominance in the field (vii, x, 2), and
promotes the idea that surgeons should only be called in cases that truly go
beyond a non-interventive practice: “los Cirujanos que llaman vulgarmente
Comadrones, los debe reservar la honestidad y decencia para los casos
únicamente en que ocurre dificultad insuperable por la Matrona; la qual
dificultad no es tan freqüente como la vana timidéz del vulgo aprehende”
(2). In this statement, Medina accomplishes three things: he recognizes the
capacity of women to manage births that have a possibility of success
without the intervention of new technologies; he linguistically denigrates his
public just as Feijoo does; and he creates a level of equality between
uneducated women and educated men. The male midwife, though referred to
here with the pejorative nomenclature of vulgarmente, was an educated
practitioner, but Medina deems him less worthy than the female midwife,
though at the time of his writing, she was relatively uninstructed in the
scientific particulars of the trade.
The interplay of praise and critique that allows the reader to access so
much in Medina’s writing is consistent in Navas’s work as well. His harshest
criticism and most politicized statements are often wrapped in seeming
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praise:
Gervasio de la Touche en 1687 mandó imprimir una obra con el título de
Muy alta y soberana ciencia del arte é industria natural de parir, contra la perversa
impericia de las mugeres que llaman comadres, cuya ignorancia hace perecer todos los
días infinitos niños y sus madres, &c. El autor se inclina á que conviene que los
hombres egerzan el arte de partear, y quiere que las mugeres mas bien
paran solas, que asistidas de las comadres, porque todas las parturientes
no carecen de los conocimientos precisos para gobernarse en sus partos,
en lo cual coincide con lo que hemos dicho de las Hebreas. (lxxviii)
This description of a work whose title alone is a vindictive assault on the
female midwife seems to give it fair representation, by following the
common pattern of introduction, description, and classical referent -a
pattern that we see in Feijoo’s letter. Yet Navas’s discussion of the ancient
Jews, sixty pages prior to this reference, makes the comparison far from
complimentary. Though the women to whom he refers to did not use
midwives, they did not face the dangerous and difficult process of birth
alone by choice, but because the Pharaoh had ordered that, on pain of
death, midwives kill all male offspring, whether they would or no (Navas
viii). This allusion doubles the negative connotations of the historical,
Biblical example as it both plays on Spain’s well-established anti-Semitism,20
and suggests that Gervasio’s theory is tantamount to filicide. Navas uses the
paradox in his description, between the men who should be in control
because women are dangerous and the women who understand how to
govern a labor, to promote the idea that women know their business. What
is more, his criticism creates a linguistic tie between the author’s message
and his readership, by the use of a first person plural in reference to the
previous episode in his text, making his readership an inherent part of the
critical process.
Navas’s history of obstetrics also offers very direct support for the
female provider’s place in the field. In discussing a 1760 book by a London
midwife, which purports to be a treatise against abuses of birthing
technologies, but which “debe titularse tratado contra los comadrones” (lxv), he
poses the question directly: “¿pero quién negará que las comadres pueden
adquirir y poseer los mismos conocimientos que los comadrones? Y
concedida esta igualdad, ¿por qué han de merecer los hombres la
preferencia?” (lxv). Navas does, however, use gendered language in a way
that plays into the empirical element of the midwife’s identity as female lay
practitioner, revolving around the rhetorical expression “dar a luz” (to give
This century’s struggle between a great need for doctors and a social repugnance
toward Jewish healthcare providers is visible in that one of the requisites for the
midwife’s licensure was proof of limpieza de sangre, going back two generations
(Usandizaga 217).
20
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birth), which he first uses to describe the publication of a book when he
references a text by female author and midwife Luisa Bourgeois: “Después
dio á luz la apología contra las declaraciones de los médicos, obra que ha
tenido varios traductores” (lxxi). While Navas’s very inclusion of works by
female authors and written in direct apposition to male-authored texts
suggests a parity in understanding, the description that he gives of
Bourgeois’s text suggests its social recognition as well, in his explicit
reference to the book’s several translations. The use of the expression that
she “birthed” her work is yet more striking in the broader context of
Navas’s history, as the majority of the literary products that he discusses are
not granted such evocative terminology, being most commonly referred to
as “published” (repeated some ninety times in the text).21
However, this expression is not solely applied to the work of female
writers: “Don Josef Bentura, cirujano comadron de Madrid, dió á luz en
1788 una obra que hace muchos años tenía compuesta” (civ). Navas then
showers praise on this birthed book: “El deseo de emplear la doctrina de
esta obra […] me estimuló á leerla con atencion luego que se publicó, y á la
verdad me admiró el buen exito de algunas de las observaciones que espone
en prueba de su doctrina” (civ). Such an introduction, combining biological
(female) creation with a high level of scholarship, lauds it as a product of
personal experience, rather than something created from sterile theory.
Indeed, in one of his numerous first person asides, Navas reiterates this
connection between creation and experience. “[E]l genio y al contínuo
egercicio que el Señor Bentura ha tenido en partear, le hacen superar con
medios inferiores á los del dia, lo que á otro le sería imposible” (civ). It is
Bentura’s constant practice and attentiveness to his craft that Navas cites as
the basis of his success, and for which he uses a metaphor for creation that
breaks the continuity of a doctrinal educational narrative, by its semantic
reference to biological reproduction.
It is through this valorization of practice over theoretical preparation
that Medina and Navas place their texts on the empirical side of the
eighteenth century’s clashing scientific epistemologies. Because Cartilla nueva
y útil was written to provide the most practical parts of a theoretical
education to practitioners of an empirical tradition, it deals from its
foundation with the conflict between rational and traditional facets of the
educational world. Interaction with both sides is clear throughout the book
in Medina’s double intended audience: the midwives to whom it is
addressed, and the elite of the medical educational system. This doubling is
clearly visible in his incessant use of the third person in referring to women,
which, in combination with the commentary that he gives justifying their
practice, creates them as object as much as addressee. He describes the
format of the book, (visible in Figure 2), as: “toda en metodo de preguntas,
21 For background on the childbirth metaphor of literary production in interaction
with the phallic energy of the pen as the instrument of creation, see Friedman.
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Johnson, "Eighteenth-Century Obstetrics Manuals"
y respuestas, y con la posible brevedad, y claridad; por que dirigiendose para
Mugeres, que apenas saben leer, y escribir, y que hasta aora, por no haverse
sujetado á studio alguno, se les ha de hacer muy ardua qualquier literaria
enseñanza”(ix). If this text were directed towards women, as he claims both
here and in its title, this explanation would not be couched in negative, third
person descriptions of that target audience. Furthermore, this depiction
suggests that his secondary audience is opposed to an educational system
based on imparting practical information rather than theory. The question
and answer catechistical structure of the book is in itself a strategy that
engages with the difference between dogmatic and scientific methods of
educational practice.
Figure 2. Don Antonio de Medina, Cartilla nueva útil y necesaria para instruirse las
Matronas, que vulgarmente se llaman Comadres, en el oficio de Partear (Madrid: Oficina de
Antonio Sanz, 1750)
In her article “Reading in Questions and Answers: The Catechism as an
Educational genre in Early Independent Spanish America,” Eugenia Roldán
Vera describes the split historical trajectory of the catechism as an
educational tool: a split that centered on the secularization and growing
accessibility of education. The formation of Medina’s question and answer
structure falls in line with seventeenth century scientific catechisms, which
strove to arrive at convincing truths behind unpopular positions through
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the presentation of opposing viewpoints, rather than with more traditional
religious instructional texts that used the format to prompt previously
memorized responses. Medina’s strategy allowed his text not only to
provide information that the midwife should memorize, but also to debunk
unfounded traditions in both lay practices and established doctrine, while
distancing the author from overly controversial opinions (24). Just as
Feijoo’s letter suggests that training women would not require the populace
to rethink its opinion of them as weak, Medina couches his desire to engage
in dialogic philosophical discussion in the assumed stupidity and laziness of
his supposed female primary audience.22
However, as for Feijoo, this stupidity is clearly superficial for Medina,
as can be seen in his proposed outcome to better education: “[S]e espera
recobren nuestras Matronas Españolas aquel famoso crédito que tuvieron
en el antigüo, que tengan en ellas, las que paren, la conveniente confianza, y
goze el Publico de el Consuelo, y satisfaccion de no exponer sus mugeres al
arbitrio de gentes sin pericia, ni practica” (x). This appeal to a golden past
ties into the ilustrados’ discontent with their retrospective, recursively
valorizing public, yet it does so in a way that suggests educated, well practiced
women as a means of accessing that former glory. Further, the “gentes sin
practica” that he mentions here, under whose care Spanish women should
not have to suffer, include university students who, at the time of his
writing, could still receive a medical degree without ever having touched
even a cadaver, let alone a living patient. This openness to categorizing
physicians as bad practitioners is supported by Medina’s distribution of
importance in theoretical areas of the art, which he weights heavily toward
anatomy and practical experience, suggesting that no book can provide a
complete education: “La verdadera idea y conocimiento de estos huesos, de
su figura, tamaño y articulación, no la pueden conseguir las Matronas por la
sola explicacion y noticia que se les dé en los libros, y así es necesario que á
presencia de Esqueleto, y de un Maëstro Anatómico lo pretendan” (10).
This assertion clearly frames educational priorities that revolve around
observationally derived knowledge, as well as demanding training for
midwives beyond his book, critiquing university faculties that lack in praxis,
and reinforcing the existence of an expected readership in the academic
elite.
As I have mentioned, Medina’s criticism of untrained practice often
22 The questions that Medina poses are simple and straightforward. E.g.: “¿Qué se
debe entender por Arte de Partear?” (1), “¿En qué se debe fundar la mejor enseñanza
del Arte de partear?” (8). His answers, on the other hand, while worded plainly, are
clearly the voice of authority both by their length, and in that the answers
themselves create discourses with other, often unfounded or false, trains of
thought. If the answerer were only giving back information that was already
conveyed, as is the case in religious catechisms, this type of discussion would not
happen.
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correlates with his description of things done vulgarmente, a term that carries
the double signifiers of “crudely” and “popularly,” which again suggests his
agreement with Feijoo’s opinion of their public. While the appellation of
both female and male midwives with the term “comadron/a” is described
in this way, he also uses it extensively to debunk folkloric interpretations of
anatomical and biological functions that empirical study would nullify: “P:
Por qué estando el feto encerrado, y nadando en esta agua los nueve meses,
no se ahoga? R: Por que dentro del útero, ni respire, ni tiene necesidad de
respirar; y por consiguiente, ni excrementa, ni llora, como vulgarmente han
creído” (23). This imagined crying, breathing fetus is a relatively extreme
example of his critiques valorizing observation over tradition, which extend
beyond myths based in folk wisdom to Hippocratic teachings. While these
teachings can be easily refutable by observation, they were canonical both
medically and legally in the period. “P. Puede haber preñez de trece ó
catorce meses, y aún de uno y dos años? R. Aunque las Leyes en favor del
próximo lo toleran, es vulgar credulidad el confesarlo” (37). Here, the law
and medical canon are demonstrated as irrational and reliant on dogma,
rather than empirical evidence. This difference between tradition and
observable truth, taken to the point that it questions established law, is
crucial. Practical experience and unbiased observation offer the truth in a
way that tradition cannot, regardless of its source material.
The negative connotation of commonality and of the term
“vulgarmente” is, however, something that can be warded off by
experience. For example, after the birth of an infant and the cutting of the
umbilical cord, “se le embolverá en los paños y pañales, que vulgarmente se
sabe” (66). This information is valuable enough to include due to of the
practical experience involved, even though it is so commonly know that it
triggers his usually critical adverb. This emphasis on experience and
observation is the foundation of much of his praise as well. “Muchos tienen
por natural, y facil tambien al parto en que la criatura presenta lo primero
ambos pies, y por ellos es extrahido sin dificultad, como cada día muestra la
experiencia” (44). Medina’s argument for empirical education is rooted in
this differentiation between observation and blind belief.
In Elementos del arte de Partear, Navas too focuses on experience as the
wellspring of knowledge. To emphasize something said or written, he
references the author’s experience rather than his/her education or
pedigree, often repeating the descriptive phrase “despues de muchos años
de práctica” (lxxxi, lxxxiii, et al.). He also distinguishes between erudition
and practical experience, with more value laid on the latter: “En fin, La
Motte es, como lo pinta Haller, no erudito, pero muy práctico, de buen
juicio, que observó mucho, que con sencillez vio mejor que sus
predecesores” (lxxxi). Navas’s positive focus on interior traits, like
judgment and skilled observation, and on practical experience, suggests that
these traits supersede a lack of erudition. In discussion of educational texts
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it is also easy to see Navas’s focus on utility over extensive rhetoric and
theoretical reference, especially when it is coupled with much field
experience:
Mr. Barbaut, comadron de las escuelas de San Cosme, después de muchos
annos de práctica publicó en 1775 un Curso de partos para los estudiantes y
para las comadres. El autor llenó la idea que se formó de dar á sus discípulos
un compendio de los preceptos que les enseñaba, con claridad, y sin
superfluidades. Al paso refiere el suceso de varios casos para aprobar su
doctrina. (lxxxiv)
This text, lauded for its simplicity, focus on basics, and its grounding in the
author’s experience –cited twice in this excerpt– is exemplary of the
ilustrado advancement of function over form.
Yet in the supposed simplicity of these enlightened medical texts, it is
possible to access the mix of sweetness and utility that is characteristic of
the movement, and that has value beyond their physical descriptions of
bone and knife. Antonio Medina’s Cartilla nueva util y necessaria para instruise
las matronas que vulgarmente se llaman Comadres en el oficio de Partear, Juan de
Navas’s Elementos del arte de Partear, and Benito Jerónimo Feijoo’s “Uso más
honesto de la arte Obstetricia” offer insight into the epistemological
confrontation that so influenced the reformative power of Spain’s ilustrados
through their textual constructions of the midwife. By her position as
adjacent and necessary to, yet separate from the male medical hierarchy, the
eighteenth century midwife becomes the crucible for a shift in worldviews.
The role that this textual midwife plays, in spite and because of the abuse
that she receives, suggests that she, along with her socio-medical milieu, is a
figure crying out for further investigation.
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Cunningham, Gary F., Kenneth J. Leveno, Steven L. Bloom, et al. Williams
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